engagement they have with the person being cared for
(Tanner, 2006). Person-centredness refers to the quality of
the relationship that occurs at the clinician–patient interface
when the clinician ‘knows’ not only themselves but also the
patient, in a holistic sense that is not just related to the
person’s physiology or illness history (O’Neill, Dluhy &
Chin, 2005). Clinical reasoning that is undertaken without
full engagement by the nurse or midwife may result in
processes that are ritualised or depersonalised.
However, not all processes of care require the same
degree of engagement; in some cases a high level of engage-
ment may be inappropriate to the situation. When the level
of engagement does not match the patient’s needs, it can
detract from the quality of the reasoning, the interaction and
the creation of a therapeutic relationship. Therefore, one of
the skills required of the nurse or midwife is to match the
level of engagement to the needs of the person (Table 14-1).
In these situations, the competence of the clinician is para-
mount in making decisions regarding the level of
engagement that is appropriate. For this reason, being
empathic, listening well and showing an ability to imagine
others’ feelings and difficulties are also important attributes
in reasoning ability (Alfaro-LeFevre, 2012).
Willingness to put all the pieces together
Recall the list of personal attributes required for person-
centred care in Box 1-5 in Chapter 1. Two important
attributes were motivation and moral agency. These attrib-
utes are also essential for clinical reasoning. Motivation is
the potential within the individual that accounts for consis-
tency of effort expended in carrying out the required
activities of the clinician (Janssen, de Jonge & Bakker,
1999). Moral agency involves translating ethical principles
into action.
Nurses and midwives are acknowledged as key personnel
in collecting the data that underpin decisions and actions in
Unit III Thoughtful practice and the process of care
256
healthcare (Levett-Jones & Hoffman, 2013). Clinical reason-
ing requires clinicians to put together what is seen, heard and
known into a coherent whole in order to come to a judgement
(DiVito-Thomas, 2005). A desire to do one’s best work
(
motivation
), combined with a desire to do what is right for
the person (
moral agency
), enhances the clinician’s ability
to ‘put the pieces together’, looking beyond the known to the
unknown when seeking solutions and thus improving the
reasoning process (Fowler, 1998). To achieve excellence in
reasoning that is driven by high levels of motivation and
moral agency, clinicians are required to be motivated,
genuine, honest and upright. The person doing the reasoning
must seek the truth, even if it sheds unwanted light, must
be knowledgeable, flexible and open-minded (Paans et al.,
2012), must admit flaws in their own thinking, and must be
willing to admit to mistakes and learn from them. Clinicians
must also be able to reason in a professional way, taking into
account policies and procedures, professional standards, law
and ethics (Alfaro-LeFevre, 2012).
Willingness to make a decision
Clinical reasoning has also been shown to be influenced by
the confidence of the clinician and the clinician’s levels of
anxiety experienced in the situation (O’Neill, Dluhy &
Chin, 2005). Anxiety can cause a novice clinician to over-
look significant cues and thus can lead to poor reasoning,
judgement and decision making. The influence of anxiety
on reasoning can be mitigated by the presence of supervi-
sion or support from more experienced clinicians who are
available for consultation and discussion related to the sig-
nificance of the cues. Clarity of roles and responsibilities
also helps to make reasoning a less anxiety-provoking
activity, thereby improving its effectiveness. The Nursing
and Midwifery Board of Australia (NMBA) (2007) has
developed a framework to assist clinicians in developing
skills in decision making.
Full engagement or total connectedness
between the clinician and the patient
TABLE 14-1 Levels of engagement that affect reasoning and the process of care
Level of engagement
Description of engaged practice
The clinician participates in shared decision making with the patient in
order to be able to recognise a problem, collect the full range of cues
needed to enable sound clinical reasoning and negotiate a plan of care
that reflects the values and beliefs of the patient.
Partial engagement, or where a problem
or the context affects the relationship
between the clinician and the patient
This may occur when the clinician does not know the patient or when the
context and priorities of the moment do not allow for the building of a
therapeutic relationship (e.g. when the clinician is part of a visiting resus-
citation team). Reasoning can be affected by incomplete information.
Disengagement, or where there is no
relationship between the clinician and the
patient, or where the relationship is
dominated by ritual or routine actions
There is no encouragement for the patient to participate in decisions
related to their care. Reasoning is dominated by factors other than
patient’s needs and values.
Source: McCormack & McCance, 2010.
